4. Outputs and outcomes by objective.
4.2 The capacity of the Division of Population was strengthened with overseas training, study tours, and on-the-job technical assistance, but this Department remains understaffed relative to the scope of its mandate. Technical training was provided in demography, the use of demographic data in development planning and the implementation, management, and monitoring and evaluation of the population policy and program. However, the amount of demographic training (both in numbers of people trained and length of training) was inadequate for the needs (Wakam 2001). The effectiveness of training delivered was not evaluated. Participation at the 1994 Cairo Conference on Population and study tours to Burkina Faso, Mali, Senegal, and Tunisia increased the exposure of staff to international good practices. Training was also provided to over 60 public sector officials in the use of demographic data in development planning by all ministries, but utilization of demographic data has remained weak (Wakam 2001).
4.3 The project was generally successful in raising community awareness and disseminating the population policy, but attitudes are slow to change. At the MTR and again at the close of the project it was acknowledged that it takes considerable time to change attitudes. Nevertheless, during its field visits the mission was told about and also observed evolution in knowledge and attitudes across a wide range of groups. (41) For example, religious leaders (Muslim and Christian) are involved members of local-level population commissions and are highly committed to population policy objectives that aim to improve mother and child health and wellbeing and girls' schooling. National and international informants noted that some (initially resistant) imams are now sufficiently convinced about the benefits of birth spacing that they are promoting this practice in rural populations. This being said, there is still ambivalence and even resistance to the idea of limiting family size, whereas other components of the population policy (child spacing to promote of maternal and child health, improvement of women's status, and expansion of women's economic opportunities) are more widely supported. While the coverage targets of population IEC were essentially met, the efficiency of efforts was compromised by the delay in the creation of a technical coordination committee for IEC (42) and the failure of this committee to meet regularly.
4.4 The project was successful in generating relevant socio-demographic data and information in Chad, but it is not fully exploited. The three main research outputs of the project were: (a) the first Demographic and Health Survey (1996/97); (b) a study on migration and urbanization; and (c) the preparation of 15 monographs that provide for each prefecture regional-level data drawn from the 1993 census, five in-depth analyses of census data, and seven regional-level analyses of DHS data. The extent to which this data is used in development planning and evaluation has been reviewed and judged to be very weak (Wakam 2001). In addition, delays in the publication of completed studies undermine efforts to disseminate and use them. A case in point was the migration and urbanization study, which was published three years after its completion.
4.5 The project strengthened MCH/family well-being services at all levels of the public health system, most notably through the supply of contraceptives for these services throughout the life of the project. As a complement to the ongoing Health and Safe Motherhood Project, which sought to strengthen basic health services, the project averted a major gap in contraceptive supplies when USAID withdrew support to Chad in 1995. USAID had been the main supplier of contraceptives in Chad; in the absence of project support, there would likely have been a severe shortage of contraceptives in the country. Close coordination between these two projects, including joint supervision, ensured a coherence in the provision of inputs for MCH and family well-being. Other supports to MCH and family well-being included: (a) subprojects supported by the social fund to improve MCH and family well-being; (b) the production of critical baseline data on MCH and family well-being (DHS 1996/97); and (c) the improved availability and affordability of oral rehydration therapy throughout the country.
4.6 The social fund was successful in mobilizing and financing a response from civil society organizations in addressing population issues and in inciting and supporting an integrated public sector response at decentralized levels of the administration. Forty-five population subprojects (against 20 planned) were carried out. Of these, 30 were executed by local associations supporting a variety of activities (maternal and child health and family well-being, promotion of women and youth, and studies), and 15 integrated projects (addressing direct and indirect determinants of population and reproductive health) were implemented by the 15 CRPRH.
4.7 Evaluations of subprojects commissioned by the social fund focused more on implementation rates than on results. However, field discussions highlighted results reported by implementers and beneficiaries, including an increase in the use of prenatal services, improved economic opportunities for youth, increased enrollment of girls in school, increases in exclusive breastfeeding, and a reduction in severe cases of malnutrition among children.
4.8 The provision of microfinance for poor women achieved positive changes in important, inter-related determinants of fertility: (a) increased income generation and economic opportunities for women; (b) increased investments in the health, nutrition and education of their children; (c) improved social and economic status of women; and (d) improved information on reproductive health and family health. These achievements, relative to the counterfactual of no support, are documented both in the final evaluation of the microfinance component (Miller 2001) and in discussions with about 50 beneficiaries of this support the cities of Mao, Bongor, Moundou and Mongo. Informed questions posed by these women about the relative safety and risks of different methods of contraception provided an indication of their basic knowledge and internalization of messages about reproductive health and family planning choices. However, as is documented later in this chapter, these achievements have not yet translated into increases in the CPR.
4.9 The introduction of oral rehydration packets into the social marketing portfolio of AMASOT to fight diarrhea in children under five addressed yet another critical determinant offertility--that of high child mortality. Sales thus far have exceeded initial expectations due to a very high demand for this product. The potential impact of this activity on child mortality is significant, but it has not yet been evaluated.
4.10 Project assistance did not succeed in increasing the modern contraceptive prevalence rate (CPR) from an estimated 1 percent in 1990 to the target of 10 percent by 2000. (43) As illustrated in Figure 2, Chad achieved a modern CPR prevalence rate of 2.0 percent in 2000 (UNICEF 2001), a statistically significant increase over the 1996 level of 1.2 percent (DHS 1996/97), but, nevertheless, considerably lower than the target. The figure also shows that the CPR for modern and traditional contraception combined increased from 4.2 percent to 7.9 percent over the same period. Table 3 in Annex D shows a breakdown in contraceptive use by level of education and place of residence in 2000. The modern CPR is significantly higher among women with secondary school education (12.3 percent) as opposed to those with primary education (2.8 percent) or some education (1.4 percent); and modern CPR is also higher among women living in urban areas (6.6 percent), especially in N'Djamena (9.0 percent), as opposed to their rural counterparts (0.8 percent).
4.11 Available data indicate that the total fertility rate (TFR) in Chad has remained constant over the life of the project. The DHS revealed a TFR of 6.6 children in 1996/97; recent analytic work suggests this same rate for 2000 (CSR 2004).
4.12 The population strategy also aimed, through an anticipated increase in the CPR, to reduce the annual rate of population growth from 2.4 percent in 1990 to 2 percent by 1999. According to the most recent Government estimates, the actual rate of population growth is about 3.1 percent. (44)
4.13 It is important to note that at the time of the MTR (1997), when the results of the first-ever DHS in Chad became available, it was acknowledged by the Bank and the borrower that the objectives of increasing the use of modern contraceptives and decreasing fertility and the population growth rate were, in retrospect, not realistic and would not be achieved. They expressed the intention of setting new targets on the basis of the DHS data. UNFPA hired consultants to this end, but the work of these consultants progressed slowly; and the Development Credit Agreement was not formally amended to set more realistic objectives against which the project would be measured.
4.14 Epidemiological and behavioral surveillance was improved under the project and documented the seriousness and scope of the epidemic. The project supported the strengthening and functioning of the epidemiological surveillance system for HIV, comprised of nine fully functional sentinel sites (45) by the end of the project (versus seven planned), two of which were set up with project assistance (see list in Annex D). This system collects and reports annual data on HIV prevalence among pregnant women using prenatal services, blood donors, STD patients, and TB patients. (46) Sentinel sites also monitor and report on prevalence of syphilis among women using prenatal services. Technical supervision and support of sentinel sites was somewhat constrained by staff turnover, (47) but compensated in part by the support of the long-term technical assistant. (48)
4.15 HIV prevalence and behavioral studies have supported the documentation of trends, issues, and consequences of the epidemic and the development of strategies on how best to fight it. HIV seroprevalence studies in different geographical regions, some focusing on the general population others focusing on specific high-risk groups, have permitted in some cases an assessment of trends in the epidemic (see Annex D). Sentinel sites and studies data were often cited by regional authorities and actors and may well be motivating local commitment and, to a lesser extent, the design and targeting of activities. Also contributing to improved knowledge and insight were: knowledge, attitude and practice (KAP) surveys and sociological studies on high-risk groups (such as prostitutes) and a study to assess the economic and social impact of the epidemic.
4.16 The IEC Unit within PNLS produced materials and carried out campaigns to inform the general population and target groups and enhance their ability to protect themselves. These efforts were complemented by the numerous and widespread IEC efforts carried out by other national partners (such as the Ministry of Communication, the IEC division of MoPH, and public and non-public actors at the local level) targeting many groups across the country. Many actors encountered during field visits acknowledged the good quality and utility of IEC material produced by the IEC unit in PNLS. Many also called for more locally appropriate material in local languages, better coordination of IEC, and more research for adjusting interventions and target groups. There was consensus among the majority of informants that evolution has occurred in the knowledge and attitudes of a range of actors and stakeholders. HIV/ADDS is no longer taboo, but rather recognized for what it is: a threat to the development of Chad and the well-being of its population that requires urgent and persistent action. While IEC efforts do seem to have had some impact, their coordination and efficiency are in need of improvement.
4.17 The project supported the strengthening of the public health system's capacity in: the diagnosis of HIV infection (including equipment of laboratories), the psycho-medico-social care of HIV/AIDS patients, the diagnosis and treatment of opportunistic infections, and STD syndromic treatment. (49) The project provided technical training and consumables for laboratories and established a national laboratory referral center for HIV/AIDS diagnosis. It also financed a CD4 count instrument and the establishment of Enzyme-Linked Immuno Sorbent Assay (ELISA) chains in five hospitals. Support for improved STD services included the training of over 2000 service providers and the preparation of STD treatment guidelines. Some training on the use of anti-retroviral drugs (ARV) and triple therapy was also provided. (50) No evaluation has been carried out to assess the extent to which these investments culminated in more and higher-quality services. A number of those interviewed noted that FHV/AIDS and STD patients are still not well managed and that there are still considerable gaps between facility-based and community-based care. Data were not available to check progress against the project target of 12,000 AIDS patients being treated by the health system. The project also invested in the strengthening and expansion of counseling and testing services; at the end of the project some 13 centers were functioning (target not specified in project documentation), with more slated to be established.
4.18 The social marketing program has significantly increased the availability of condoms in Chad at an affordable price. A total of 19.9 million condoms were sold during the life of the project (1996-2001) through a network of over 1,200 points of sale throughout the country, against the initial target of 14 million. The annual sales target set for the last year of the project (4.8 million condoms) was exceeded in the third full year of the project (6.5 million in 1999). For reasons explained in Chapter 3, annual sales declined temporarily in 2000, then steadily increased over the following two years, achieving 4.0 million in 2002. Figure 3 shows trends in annual sales over the life of the project and during the first year after the close of the project (2002). Annex D shows a further breakdown of these sales by month and average monthly sales for each year Oust under 300,000 condoms).
4.19 The very low price of less than US$0.02 per unit (50 CFA francs for a packet of four) has made condoms widely accessible to the general population. It has also prompted the sale of these condoms in neighboring countries of Cameroon and Central African Republic, where the price of condoms is higher. A study of social marketing programs in the three countries estimated that up to 20 percent of AMASOT condoms (about 4 million units) may have been resold in these countries (Lehmann et al. 2003). Net of estimated sales in neighboring countries, the total number of condoms sold in Chad over the life of the project (15.9 million) still exceeded the project target of 14 million. In October 2003, AMASOT increased the price of condoms to 100 CFA francs. (51)
4.20 While condoms were taboo at the start of the project, they are now sold openly in shops, market stands, inns, and hotels across the country. The Bank evaluation mission was told by the majority of those interviewed that condoms are used more frequently during casual sexual encounters. (52) There are now some 25 billboards with HIV/AIDS messages prominently displayed in major cities. Messages abound as well in newspapers and on posters placed in many public venues: workplace, stadium, restaurants, hotels, and public transport. Religious institutions and leaders who were vehemently against condom promotion at the project's outset have tempered their opinions and have a laissez-faire demeanor, with some tacitly promoting their use as a means of preserving family health and well-being. As a consequence, there seems to be considerably less stigma associated with the purchase of condoms.
4.21 The social fund has been complementary to AIDS interventions carried out by Government. A total of 97 HIV/AIDS subprojects were prepared and implemented throughout the country (against 40 planned), of which 68 by local associations (prevention targeted at youth, prostitutes, and psycho-social-medical care), three by regional Islamic associations (in three prefectures), 15 integrated projects under the coordination of Prefecture Health Councils, and 11 by eight sector ministries. (53) The impact of these efforts has not been evaluated, but the social fund has achieved an expansion of national capacity to respond to HIV/AIDS and has broadened the range of actors and scope of activities.
4.22 The social fund has nurtured and supported a response from civil society organizations in addressing HIV/AIDS: Civil society projects covered a range of advocacy, IEC, behavior change interventions, and community-based efforts to provide care and social support to people living with HIV/AIDS (PLWHA). Field discussions with implementers and beneficiaries pointed to improved awareness and knowledge, better quality of life for PLWHA and their families, and greater civil society pressure on public sector leaders to be accountable for addressing HIV/AIDS.
4.23 The social fund has also strengthened the capacity of civil society to conceive and implement activities in support of HIV/AIDS. Six experienced NGOs carried out capacity development activities, based in, and covering, different geographical zones across the territory of Chad. Assistance included subproject design, proposal writing, implementation, and monitoring and evaluation. This approach put needed technical assistance and support within immediate access of a relatively inexperienced and weak civil society. A significant majority of the numerous local associations interviewed during the evaluation mission considered this assistance to be pivotal in their ability to access funds and implement subprojects successfully. Another outcome of the efforts of the capacity building efforts is the development of new local associations, in particular associations of prostitutes and associations of PLWHA. This is an important accomplishment, given taboos prevalent at the project's outset and given the great potential of these two groups to contribute to HIV/AIDS prevention efforts. A number of experienced NGOs raised concern about the limits of their ability to provide effective support to the increasing number of local associations with limits in financial and human resources defined in their contracts.
4.24 Improved capacity of poor women to earn income under the microfinance component, combined with the provision of practical information on HIV/AIDS decreased the vulnerability of women to HIV infection. An evaluation of this subcomponent was undertaken (Miller 2001) (54) and corroborates the findings of the mission, derived through interviews with microfinance agencies and about 50 women beneficiaries in four prefectures. The large majority of women's groups succeeded in using microfinance resources to start or expand economic activities that resulted in increased income used for investments in family well-being. Together, the extra income and the information on HIV/AIDS were reported to have given women an equal partnership with their husbands, higher self esteem and dignity, and the knowledge to protect themselves from HIV infection. Women benefiting from this assistance reported that it protected them informal prostitution for income and equipped them to reduce vulnerabilities of their daughters and other women. In short, they expressed a strong sense of economic, social and personal empowerment.
4.25 The social fund mobilized and financed the involvement of key sector ministries in HIV/AIDS efforts. The social fund has supported HIV/AIDS activities of eight key ministries, who have designated a focal person and, in some cases HIV/AIDS units, to address HIV/AIDS issues, targeted at staff and clients. Among activities supported are: HIV/ADDS training and IEC in schools (Ministry of Education), social support of PLWHA and their families (Ministry of Social Action and Family), medical and social support of HIV/AIDS patients (Ministry of Public Health), training of journalists, and radio and television media campaigns (Ministry of Communications), sensitization of military and prevention of contamination in health facilities (Ministry of Defense), protection of prisoners (Ministry of Justice), information and mobilization of local officials and traditional leaders (Ministry of Interior). However, the effectiveness of these activities has not been evaluated.
4.26 The social fund launched and supported the decentralization of HIV/AIDS activities in all 14prefectures. Carried out under the auspices of inter-sectoral Prefecture Health Councils, the effectiveness of the subprojects, focusing on a range of prevention, care, and mitigation activities, has not been evaluated. Over and above the financing of these activities at the regional and subregional level, project support provided a dynamic for local-level, inter-sectoral deliberation and action on HIV/AIDS.
4.27 Awareness and knowledge of HIV/AIDS, among men and women, both urban and rural, have increased during the life of the project. (55) The most significant improvements found among women, rural residents and the poorest income quintiles (see text Figures 4, 5, 6, and 7; and Annex D). Improvements have thus reduced important disparities in knowledge and awareness between men and women, urban and rural residents, and the poorest and richest segments of the population. Trends in knowledge of high risk groups are not known. (56)
[FIGURE 7 OMITTED]
4.28 The proportion of adults reporting that they have ever used a condoms has risen over the period 1996-2003, with the most significant increase among women (Figure 8). While urban-rural and gender differentials are still evident in 2003, they have been reduced since 1996/97.
4.29 In 2003, 6.6 percent of women surveyed reported using condoms regularly and another 6.5 percent of women reported using them occasionally, higher than in 1996/97, when 0.7 percent of women having knowledge of AIDS and having sexual relations within the last 12 months reported using a condom in their most recent sexual encounter (DHS 1997). Men also reported higher levels of condom use than women in 2003 than in 1996/97: 8.7 percent reported regular use and 9.1 percent reported occasional use in 2003, up from 2.2 "percent of men knowing about AIDS and having sexual relations within the past 12 months reported using a condom in their most recent sexual encounter (DHS 1997). Trends in condom use by high-risk groups have not been systematically tracked, but a recent study reveals high rates of condom use by prostitutes. (57)
4.30 In the absence of incidence data, it is difficult to evaluate the extent to which the project has slowed the spread of HIV infection. (58) At the time of project design 2,865 ADDS cases had been reported over the 9-year period 1986-1994. During the following eight-year period (1995-2002) an additional 14,108 cases were reported, a fivefold increase. However, even the most recently reported cases were most likely the result of infections which occurred before the start of the project and AIDS cases are underreported.
4.31 A series of population-based surveys of general and specific populations reveal HIV prevalence rates for different geographical regions, different population groups, and different periods (Annex D). These data for the most part show snapshots of rates of certain groups and/or regions at a certain time. The only trends that these datashow are (a) an increase in the prevalence rates in the cities of Sarh, Abeche and Bongor (see Figure 9), and (b) a slight decline in the prevalence among military personnel in N'Djamena (from 10.2 percent in 1995 to 8.40 percent in 1997). (59)
4.32 Figure 10 shows that prevalence among women using prenatal services in four urban sites (60) has increased from 4.0 percent in 1999 to 7.5 percent in 2001 and then decreased to 6.4 percent in 2002. (61) While available data reveal that HIV prevalence has risen over the past decade in the general population and that it may have stabilized among pregnant women using prenatal services in urban areas, these data do not reveal the extent to which changes in prevalence are due, on the one hand, to rising mortality due to ADDS, and, on the other hand, to reductions in new infections.
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|Title Annotation:||PROJECT PERFORMANCE ASSESSMENT REPORT CHAD POPULATION AND AIDS CONTROL PROJECT (CREDIT NO. 2692) MARCH 7, 2005|
|Publication:||Chad - Population and AIDS Control Project|
|Date:||Mar 7, 2005|
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